Provider Demographics
NPI:1215204029
Name:PLATTE DENTAL CLINIC
Entity Type:Organization
Organization Name:PLATTE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRIESE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-337-3810
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:601 E. 7TH ST. STE #5
Mailing Address - City:PLATTE
Mailing Address - State:SD
Mailing Address - Zip Code:57369-0250
Mailing Address - Country:US
Mailing Address - Phone:605-337-3810
Mailing Address - Fax:605-337-2617
Practice Address - Street 1:601 E. 7TH ST.
Practice Address - Street 2:STE #5
Practice Address - City:PLATTE
Practice Address - State:SD
Practice Address - Zip Code:57369-0250
Practice Address - Country:US
Practice Address - Phone:605-337-3810
Practice Address - Fax:605-337-2617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM6831223G0001X
SDM9251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7805980Medicaid
NE10025648200Medicaid